Wednesday, February 29, 2012

Family Medicine: After Hours and Night Call

The cell phone chimes at the end of the work day.  It's a call from my office (where I am still seeing my last patient, or, rarely, just finished seeing the last patient of the day).  I look at the number, stop the ring and call back or answer the phone, which I already know will be our night answering system, aka our voice messaging system for after hours calls.  When the machine answers and I enter a numeric code, I get a recording noting how many new messages are waiting.  I press another time to hear the new message.  "This is your test page", I hear from the staff member still working at the check out desk in the front of the office.

I walk to the front of the office and tell that person, "I got the test page."  Every day, we have to know that our night call system is working before we leave so our patients who call after hours with problems can "leave a message for the doctor on call", as directed by our recording.  Yes, folks, your Family Doctor is available 24/7 to respond to your urgent or emergency situations.

When a patient leaves a message, the system automatically pages our doctor on call immediately, who receives a call on their cell phone just like the test page, giving them the opportunity to listen to the message immediately or when they finish their current task.  The doctor on call listens to the patient's message and phone number and returns the call.  Our machine records the patient's phone number, also, so we can listen to the recorded number via voice recording of the system immediately at the end of the patient's recorded message.  This is useful if the patient recording wasn't clear, due to the patient's illness (hoarseness, weakness, crying baby, barking dog, etc.).  Also, it's helpful for people who forget to leave their phone number or hang up without leaving a number.  Usually the person who hangs up without leaving a message actually had a need that the physician can respond to but the patient had second thoughts about bothering the physician.  I almost always call the hang ups, knowing it's always been a patient of ours who is calling.  Wrong numbers must be hearing  the recording and hang up before the paging system is activated.

What do people call about?  Someone is sick, miserable, having a reaction to medication, having no response to medication for intense symptoms, pain, acute stress reaction, clarifying whether to go to an emergency room (or urgent care).  If we advise going to an emergency room, we call the emergency room to let them know about our patient and whether we wish to be called back once a diagnosis and treatment plan is established.  We help the patient, the ER staff and ourselves by calling since we know our schedule for follow up possibilities and we know our patient and their family.  We may apprise the ER staff- usually I speak with a physician- about the past medical and personal history of the patient to provide the physician with a better starting point for understanding our patient and their situation.

I want them to sense that my patient is a unique and interesting person with a doctor who cares.  ("Please love my patient, you wonderful ER doc, you won't regret it.  I will make your work easier by willingly seeing the patient in follow up at which time I will edify the work done in the ER and the people who did it.")  We also let them know who will be admitting the patient should the need arise (we have most people admitted to a hospitalist group that we know fairly well, since we stopped admitting about two years ago.  This is worthy of another post since a new hospital just opened right next door to our office.  I love going to hospitals and caring for my own patients and want to start admitting again, BUT there are considerations about increasing complexity in all of our endeavors that may preclude admitting my own patients.  More later on this subject.).

We also let the ER doctor know whether the patient has already seen a sub-specialist in an area of concern for the current episode (if they may be having a heart problem and they have a cardiologist, we want the ER to relate to the same cardiologist and not accidentally consult another cardiology group- continuity is important).  I also let them know that if the patient is admitted, I want to speak with the admitting physician so I can give more background about my patient.  This type of personal communication helps everyone, increases "quality" and decreases the potential for disasters.

Sick babies are especially important  to us at night.  Parents can be very stressed with a sick child, so we are committed to hearing their story and connecting to the stress as well as the sickness.  The first child (what I call the "training child") generates more stress than later ones, so we add comments of validation and    reassurance when speaking with parents about the "training child".  A friendly comment to "call back if you aren't comfortable with how the child is doing or your pulse rate is over 100."  The parent, who is also our patient -one of the beautiful aspects of Family Medicine- often feels better knowing that it's ok to call back (Yes, we're in this together).

As a Family Physician, I (or my cross coverage-someone from my own practice) am available 24/7.  I get surprised when I see an ad on TV or a billboard promoting Ask a Nurse type night call companies and think, "Why ask a nurse when you can ask your own personal Family Physician?"  There must be physician groups with less availability at night than ours, or less curiosity or more stress.  I could see a patient use of Nurse on- call companies for when the patient doesn't get along with the doctor on cross-coverage call or doesn't agree with their advice.  The nurse may be very comforting for them.

This post was inspired by the calls I received in the last 12 hours while I've been on call.  We're very close to the Ohio flu season, so night call will get even more interesting.  What have your experiences been with after hours and night call medical interactions?

Sunday, February 26, 2012

Blog Milestone and Reflection at 25,000 Views

OK, I'll congratulate myself a bit in this post.  My Dr. Synonymous blog has reached 25,000 views.  Thank you, readers.  I have to look back on the blog and reflect a bit.  Why did I blog?  What did I write about?  What did people look at?  What generated reader response?  What mattered?

Personally, I'm pleased to have the opportunity to write, which I enjoy.  I'm on the back (screened in but not heated) porch writing now, watching our dog run around and explore the yard and the critters, including the tractor that just went through the field just to the west of us, beyond the treeline.  The birds at the feeder are twelve or so feet in front of me, pecking at the suet and cracking the sunflower seeds.  Finches, cardinals (Ohio's state bird), chickadees, tit mouses, woodpeckers, blue jays, grackles, and others show up from time to time which reminds me of life and nature.  The air is pure outside (if you don't mind the prolonged mold and early pollen levels which actually are good for business in Family Medicine- I tell many patients, as I've written in this blog, "Mucous is the state bird in Ohio"- of course you know it isn't since I noted above that it's the cardinal.) and I love the tones from the chime set six feet to the right of me that rings in the light and chilly breeze today.

Overall, the writings relate to Family Medicine and issues related thereto.  Patients are the most important aspect of the whys and wherefores of Family Medicine, so I comment a lot about patient situations and physician responses.  The history of Family Medicine gets several posts as does the ongoing training of Family Physicians.  I reveal some aspects about physician thinking, diagnosing and treating and comment often about how patients may connect to the physician process of working and caring.

The situation of healthcare bankrupting America shamelessly gets attention in the Dr. Synonymous blog along with lamentations about the gradual disappearance of Family Medicine for financial considerations, even when the major lifeline for the entire health care system seems to be Family Medicine (says the Family Physician, humbly).  Some posts note how we might learn a lot from others such as Dr. Marcus Welby and Dog the Bounty Hunter, while others reflect on the "Founders of Family Medicine".  The Patient Centered Medical Home (PCMH) gets a few words for being a good idea while the Human Centered Health Home (HCHH) gets numerous posts as an upgrade to the PCMH.

The Medical Industrial Complex is not favored in my writings, since I see it as so misaligned with the needs of the citizenry.  Yet, I'm part of it.  The paradox hasn't received enough of my writing in this blog, yet.

Several posts refer to days of the week to give a glimpse of what may be happening in a Family Physician's office in a particular time frame, such as Friday morning or Monday morning or Saturday morning in Family Medicine.  Specific processes such as House calls, end of life care, relationship to nurses and nurse practitioners are singled out for the readers.  Special people such as unit secretaries in hospitals, hospice nurses, patients and families also get extra focus.  My most viewed post at present "Corporatizing Hospice- More Heart Needed" laments an over-emphasis on corporate thinking to the detriment of patient care.  Many echo a plea to save Family Medicine because it is needed as a Medical Specialty that helps people and saves money.

As a Vietnam Veteran and graduate of West Point, several of the posts are my thoughts about those experiences relating to the military, war, West Point and the West Point Alumni Glee Club (one of my current top 5 most viewed posts).  Patriotic themes float through my comments about The Wall (Vietnam Veterans Memorial), Memorial Day, Independence Day (also one of my top five most viewed posts).  The anniversary of my going to and returning from Vietnam seem to get posts as does the anniversary of the "Peace" in Vietnam.  Those 20 members of the West Point class of 1968 who died in the struggle in Vietnam are constant reminders about war and peace, life and death, and truth and lies.

Human relationships and human processes seem to be at the heart of my posts.  As a Family Physician for over thirty years, I've been impressed by the human spirit.   I've tried to write about it.  I will continue

Thanks to the people who've helped with my learning about how to blog and how to write and especially to those who read my posts.  Your views and your comments have kept me sensitive to the needs of readers and patients and Family Physicians.  More reflections at 50,000 views.  Peace. apj

Sunday, February 19, 2012

Family Medicine: Marcus Welby, MD - Caring, Angry and Committed

I'm viewing the first season of Marcus Welby, MD on DVD to reflect on how the early TV doctors practiced (acted).  I was surprised to see how angry Dr Welby was on numerous occasions (in sunny California, even).  He was totally committed to his patients and to his community reputation of "Doctor", but the amount of anger surprised me.

For some background, in case you don't remember of weren't alive then, in the 1960's and 1970's, patients saw their personal physician, and usually paid for the doctor's services on the way out of the office.  Insurance was only used for hospitalization, not for office or outpatient services.  Diagnostic support such as CT scans or MRI's were just being invented in the late 1970's.  Dr. Welby and his young associate, Dr. Steve Kiley, had to do it all from cradle to grave, sometimes with the help of their local hospital- where they admitted their own patients, delivered their babies, removed their tonsils and maintained professional relationships with other physicians.

In such an era, the "presence" of the physician was a major aspect of treatment.  The doctor was committed to your well-being as long as you honored their profession and followed doctor's orders.  Just as now, many individuals disagreed with Dr. Welby (even Dr Kiley disagreed at one point or another during most of the shows in the season one DVD that I viewed).  "Therapeutic Presence" was important in the world of Welby and Kiley.  At times, they had little to offer medically, so the patient-physician relationship was very important as a therapeutic element.

Dr. Welby at times was very possessive of his patients, even demanding and angry when others interfered in their relationship.  Anger was a visitor every week from the TV doctor who had just experienced a long run as the fatherly lead in "Father Knows Best", which used the same house front as "Marcus Welby, MD".  Dr. Welby compensated with 24/7 willingness to be there for his patients- in their home, in the hospital or at the local "trailer park"- and with the motherly support as office assistant and sometime lunch preparer of Elena Verdugo who played Consuelo Lopez.

Everyone seemed to love Consuelo and most were forgiving of the youthful, geeky bluntness of Dr Kiley who lived in the house with Dr. Welby that doubled as their doctor's office.  Only Marcus Welby, MD had to get the full brunt of various angry patients or their relatives.  Still, he persisted, and confronted and hugged and argued.  He pleaded for an autistic boy to be treated by a research center and basically berated the Medical Director who politely apologized for society's failure to take care of all.  He lived in the home of that boy empathizing with his parents about the possible need to institutionalize the boy out of concern for the safety of the new baby in the home.  Never fear, Welby taught the boy to feed the horse and colt, suddenly seeing the boy connect with animals and humans at the midnight hour (end of show) as a reward for the good doctor's extra care.

I can't wait to get season two to watch the maturing of the characters and the script.  What do you remember about the "Marcus Welby, MD" show?

Saturday, February 18, 2012

Family Medicine: Radiation Safety Miracle- Informed Consent

Radiation Safety:  Another first on Emergency Department visit report, "Discussed with____(patient) criteria for CT head and facial bones giving exposure radiation versus benefit of imaging study. After considering that ___(patient) has decided against CT scans."

Could we ACTUALLY be discussing benefits and harms of CT scans and documenting informed consent for them in emergency departments?  I have NEVER seen such a statement in a report from an adult emergency department in the Dayton, Ohio area before today.  I have many patients in ED's for episodes of trauma, dizziness, confusion, etc who get CT scans. This has NEVER happened in a report about any of my patients in Emergency Departments before today.

I don't have enough children going to Dayton Children's Hospital to know what is happening there, so my comments only apply to adult emergency departments.

It's like a miracle has happened.  I'm encouraged.  What do you think?

Wednesday, February 15, 2012

Family Medicine: Odds and Ends

Caretaker stress.  We see so many people who are caring for an aging parent and get trapped with a variety of symptoms and sicknesses.  Once the aging parent gets relief, the caretaker starts to recover- usually.

A physician calls looking for a job.  Was working in campus health center, but cut-backs eliminated his position.  He'll do part time or full time.  Oops, he's not board certified, didn't finish his Family Medicine residency program.  Sorry, we aren't able to help him since we have to be board certified to get hospital privileges.  We're only admitting newborns at present, but may occasionally provide medical management on our patients when the new hospital opens next door to our office.  We'll see what happens.  Sorry, Doctor, we're unable to help you with your job needs.  We're committed to remaining board certified in Family Medicine.  It's still part of our identity.

Marcus Welby, MD season 1 on DVD.  Makes me very thankful that the GP's invented Family Medicine education via residency training, including behavioral skills.  We had a 3 year training program instead of their internship plus, in many cases, some time in the military.  Each training program must include a behavioral science faculty.  Stress, family issues, end of life issues, cultural issues, time management, career planning, interpersonal skills, mental health problems, etc. were all part of our training.  Poor Marcus Welby, MD and Steve Kiley, MD, his young associate- trial and error was their teacher. America watched as they learned together, or from Dr. Welby's vast experience and fatherly countenance.

A new hospital opens in one week next door to my office.  My office staff and I went to the open house tonight.  We got tours and munchies and brochures, not to mention coffee cups and thermos bottles with the hospital name and system logo.  They say they're having a safer strategy for medical radiation exposure.  A new approach to patient radiation safety should make them popular.

New pain law.  We have to look up patient controlled substance history on our state network.  It takes 30 days or so to get approved for access to the network.  Lots of physicians are discouraged by the pain law mandates that impact patients via physicians bailing out.

Thursday, February 9, 2012

Family Medicine: Boundaries and Relationships

The patient with several chronic diseases was in for a quarterly visit relating to three of the diseases and medications related thereto.  A new musculoskeletal problem slipped into the conversation, warranting a temporary detour from the chronic disease focus.  As we were wrapping up the visit, the patient added, "I am scheduled to get an osteoporosis scan next week.  My gynecologist ordered it."

I knew that I had ordered and interpreted her last two DEXA scans for osteoporosis, so I quickly looked at them, noting that the patient had osteopenia (a category invented to push people-mostly women- into earlier use of pharmaceuticals .  She had increased her focus on her bone health, including dietary, exercise and supplement use (Calcium, Vitamin D3, magnesium and soy isoflavones).  She did not wish to take bisphosphonates such as Actonel, Fosamax or hormone replacement therapy, such as estrogen.

I then commented that I was concerned that another physician was going to get involved in her bone health and possibly generate confusion..  It was also possible that the test, ordered at a hospital where they charged a "facility fee", not covered by insurance, would cost the patient more.  I expressed my concerns about the confusion that can happen when extra physicians get involved in ordering tests for patients, but this was her year to get the next test anyway and we could clarify how the test results related to her bone health if there was a problem with multiple perspectives.  She may wish to go ahead with the test and please make sure that I am copied on the results.  She decided to go ahead with the test.

Two weeks later, she made an urgent appointment with me to review the test results from the test I hadn't ordered, since she disagreed with the treatment strategy recommended by her gynecologist and received in the mail by the patient one day before the urgent visit with me.  The newest intravenous bisphosphonate (Reclast) and another injectable medication (Forteo) were offered my patient, who was to read about the drugs and select one that the gyn office would arrange for my patient to take.  The patient read the materials respectfully and became quite anxious.

I responded to her fears about the medication and commented about our long term concern about bone health due to the increasing life expectancy of women (81.1 years is the average in the US) and,  therefore,the increasing risks for fractures of the hip and spine.  I commented about how physicians are prone to action, but that patients get to decide what they really want to do.  I sought clarification from her about how she wished to relate to me and her gynecologist about this issue.  "The gynecologist and I seem to  have different perspectives about bone health," but would both want good health for our patients.  I apologized for my profession adding to the confusion by overlapping perspectives about her bone health.

I was annoyed that the gyn had not clarified with our mutual patient how she wanted her bone health attended to and who had ordered and acted on her last two DEXA scans.  We each have a relationship with the patient.  We each have a scope of practice that includes overlap with each other's specialties.  How do we work through the boundary issues?  How do we define our respective roles as medical specialists (Family Medicine for me and Gynecologist for her)?

In the "old days" the physicians knew each other through relationships at the hospital where all admitted or consulted on patients.  We had face to face clarifications about who would do what and why.  We could professionally disagree, but continue in a professional relationship as we gradually defined how we went about our physicianly tasks and responsibilities.  We had a continuing sense of relationship with medical ethics which we shared through committee work, positions on the hospital medical staff and interactions in the county medical society.  Those interactions are now few and far between.  We don't all go to the hospital any more.  We barely have any meetings.  What is going to happen?

How are we going to relate for the good of our patients and our profession?

Wednesday, February 8, 2012

Family Medicine: What is Our Essence?

Is Family Medicine losing its identity?  Is the specialty, its leaders and its members selling out?  Is Family Medicine only "Primary Care"?  Do Family Physicians still exist?  Or are they Family Practitioners?  Or Family Medicine Practitioners?  Or Primary Care Practitioners?  Or Primary Care Physicians?

As we seek to serve our patients, our communities and our nation during this time of health care crisis and confusion, is our identity as a specialist in a particular specialty important?  Is any medical specialty important?  Should ANY physician have a specialty?  Do specialties matter?  Should we just have physicians and no specialties?

Should we just have Primary Care Practitioners and Secondary Care Practitioners and Tertiary Care Practitioners?

I see Family Medicine as too willing to sell out our unique identity for short term financial or political success with governments or potential funders.  We're getting too comfortable using generic terms for who we are and what we do.  I'm proud to be a Family Physician!  I'm ecstatic about my Family Medicine specialty with it's history and traditions of service to individuals, families and communities.

I worry that the essence of Family Medicine and Family Physicians is being watered down and sold out.  What do you think?

Definition of Family Medicine
Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity. (1986) (2010 COD)  from the American Academy of Family Physicians.

Family Medicine Scope and Philosophical Statement
In summary, the family physician of today is rooted in the historical generalist tradition. The specialty is three dimensional, combining knowledge and skill with a unique process. The patient-physician relationship in the context of the family is central to this process and distinguishes family medicine from other specialties. Above all, the scope of family medicine is dynamic, expanding, and evolutionary.
(1992) (2011 COD)

Saturday, February 4, 2012

The Postphysician Era

"Is it true? Are we actually entering the "postphysician era" in which the ancient, archetypal function of a doctor will now be parceled out among medical technicians and paramedical professionals? I do not think so. But to rediscover the meaning of being a physician within the constraints of today's society will require that we know with certainty the essence of the practice of medicine, the essence of what it means to be a physician. The role of physician is fundamental to human society and culture. In one mode or another, this role has always existed. It represents the blending within the human psyche of knowledge and love, the mysterious but necessary balance between mind and heart, scientific detachment and compassionate engagement in the suffering of our fellow human beings." ...from "The Essence of Being a Physician" by Jacob Needleman, PhD

(Needleman J: The essence of being a physician-In The aim of American
medicine within the constraints of today's society-A forum. West J Med
1986Aug; 145:185-186)

These comments are over 25 years old.  Maybe we come to this point at regular intervals.  It feels like we're there again.  Will it pass?